Nocardiosis requires at least 6 months of treatment, preferably with co-trimoxazole or high doses of sulfonamides. In patients who don’t respond to sulfonamide treatment, other drugs, such as ampicillin, erythromycin, or minocycline, may be added. Treatment also includes surgical drainage of abscesses and excision of necrotic tissue. The acute phase requires complete bed rest; as the patient improves, activity can increase. A new combination drug therapy (sulfonamide, ceftriaxone, and amikacin) has also shown promise.

• 1. Sulfonamide-based therapies ^[1]

• 1.1 Pulmonary

• Preferred regimen: TMP-SMX 10 mg/kg/day (TMP) in 2-4 divided doses IV for 3-6 weeks THEN 2 DS PO bid for at least 5 months

• 1.2 Pulmonary alternatives

• Preferred regimen: Sulfisoxazole OR Sulfadiazine OR Trisulfapyrimidine 3-6 g/day in 2-4 divided doses PO OR TMP-SMX 2 DS bid up to 2 DS tid

• 1.3 CNS (AIDS, severe or disseminated disease)

• Preferred regimen: TMP-SMX 15 mg/kg/day (TMP) IV for 3-6 weeks THEN 3 DS PO bid for 6-12 months

• 1.4 CNS alternatives

• Preferred regimen: Imipenem 1000 mg IV q8h OR Ceftriaxone 2 g IV q12h OR Cefotaxime 2-3 g IV q6h AND Amikacin

• 1.5 Severe disease, compromised host, multiple sites

• Preferred regimen: TMP-SMX 15 mg/kg/day (TMP) IV AND Amikacin 7.5 mg/kg q12h OR Sulfonamide 6-12 mg/day PO

• 1.6 Sporotrichoid (cutaneous)

• Preferred regimen: TMP-SMX 1 DS bid for 4-6 months

• Note (1): Immunocompetent medicine use for 6 months; Immunosuppressed medicine for 12 months
• Note (2): Treat based on host, site of disease and in vitro activity; Sulfonamide usually preferred, must treat for 6-12 months; Preferred drugs for resistant strains are Amikacin and/or Imipenem
• Note (3): Seriously ill usually treated with IV Imipenem or Sulfonamide or Cefotaxime all potentially combined with Amikacin; less seriously ill treated with oral agents— especially TMP-SMX or Minocycline

• 2. Sulfonamide alternatives

• 2.1 Severe

• Preferred regimen (1): (For AIDS) (Imipenem 1000 mg IV q8h OR Meropenem 2 g q8h AND Amikacin 7.5 mg/kg q12h IV
• Preferred regimen (2): Cefotaxime 2-3 g q6-8h OR Ceftriaxone 2 g/day IV ± Amikacin

• 2.2 Mild

• Preferred regimen: Minocycline 100 mg bid for at least 6 months (initial treatment of local disease or maintenance)
• Alternative regimen: Amoxicillin clavulanate 875/125 mg bid OR Doxycycline OR Erythromycin OR Clarithromycin OR Linezolid OR Fluoroquinolone OR combinations for at least 6 months